Tester 'll Never " Satisfied "

MESOTHELIOMA COMMON QUESTIONS
What is Mesothelioma?
The National Cancer Institute states that: "Malignant mesothelioma, a rare form of cancer, is a disease in which cancer (malignant) cells are found in the sac lining the chest (the pleura), the lining of the abdominal cavity (the peritoneum) or the lining around the heart (the pericardium)."



What is peritoneal mesothelioma?
Peritoneal mesothelioma is a cancer of the lining of the abdominal cavity. This form of cancer makes up approximately one-fifth to one-third of the total number of mesothelioma cases diagnosed. More on peritoneal mesothelioma.
How do you get malignant mesothelioma?
Most people with malignant mesothelioma have worked on jobs where they breathed asbestos. Others have been exposed to asbestos in a household environment, often without knowing it. More about the different ways in which people have been exposed to asbestos.
How much exposure does it take to get the disease?
An exposure of as little as one or two months can result in mesothelioma 30 or 40 years later. Mesothelioma cause.
How long does it take after exposure for the disease to show up?
People exposed in the 1940s, 50s, 60s, and 70s are now being diagnosed with mesothelioma because of the long latency period of asbestos disease.
What is the prognosis for malignant mesothelioma?
Like most cancers, the prognosis for this disease often depends on how early it is diagnosed and how aggressively it is treated. Click on Treatment Options to find out more about traditional and new approaches.
Is there any promising research or are there promising drugs for mesothelioma?
Research is being conducted at various cancer centers all over the United States as well as by pharmaceutical companies. To find more about these studies, click on Clinical Trials. To read abstracts of the latest journal articles on mesothelioma research and to access these articles, click on Medical Journal Articles; or Mesothelioma News for news articles. A recent study of Alimta showed patients living much longer with Alitma than other chemotherapy drugs.
Where can I find information on living with mesothelioma?
Mesothelioma Aid is a good website for resource for families dealing with mesothelioma. It includes advice and referrals to other resources for coping with cancer, caregiving, financial challenges, and support groups. Alternatively, contact us here at Mesothelioma Web for help finding resouces for living with this disease.
What kinds of other resources are available for people with malignant mesothelioma?
There are numerous cancer web sites, some specific to mesothelioma. Because they are often difficult to locate, we have listed some relevant medical sites under Leading Cancer Links. We are always on the lookout for more so check our site often.
MESOTHELIOMA'S CAUSE - ASBESTOS EXPOSURE
At some point in our lives, nearly all of us have been exposed to asbestos in the air we breathe and the water we drink; from natural deposits in the earth, and from the deterioration of asbestos products around us. Most of us, however, do not become ill as a result of our exposure. More commonly, those who at some point are diagnosed with asbestos disease, have worked in jobs where more substantial exposure occurred over longer periods of time. Nevertheless, cases of mesothelioma have been documented as the result of lesser exposure, affecting family members of workers who came into contact with asbestos and brought it home on their clothing, skin or hair, or affecting those who lived in close proximity to asbestos manufacturing facilities. Symptoms of asbestos disease usually are not be apparent until decades after exposure.
Asbestos was used commercially in North America as early as the late 1800s, but its use increased dramatically during the World War II era when shipyards produced massive numbers of ships for the war effort. Since that time, asbestos-containing products were used by the construction and building trades, the automotive industry and the manufacturing industry. All told, more than 5,000 products contained asbestos.
For more than 50 years, products containing asbestos remained unregulated, and the manufacturers of those products continued to prosper, knowing full well that many of the millions of workers who came into contact with their products would ultimately suffer as the result of their actions. Finally, in the late 1970s, the Consumer Products Safety Commission banned the use of asbestos in wallboard patching compounds and artificial ash for gas fireplaces because the fiber could easily be released during use. In 1989, the Environmental Protection Agency banned all new use of asbestos, but uses established prior to that time were still allowed. Although awareness of the dangers of asbestos and public concern over the issue have led to a decline in domestic consumption over the years, a total ban on asbestos has not come to fruition. Asbestos is still imported, still used and still dangerous.
Although it is suggested that the number of mesothelioma cases in the U.S. has reached its peak and has begun to drop, a forecast released by the National Cancer Institute'sSurveillance, Epidemiology, and End Results Program (SEER), in April, 2003, projected the total number of American male mesothelioma cases from 2003-2054 to be approximately 71,000. This number, however, does not take into consideration events such as the World Trade Center disaster on September 11, 2001, when millions of New Yorkers were potentially exposed to air filled with carcinogenic asbestos particles. The incidence of mesothelioma cases by state and county are shown in these tables. When the latency period for asbestos disease is factored in, cases of mesothelioma will continue to be diagnosed for years to come. See our page on mesothelioma risk factors.

MESOTHELIOMA SYMPTOMS
The early symptoms of mesothelioma are generally non-specific, and may lead to a delay in diagnosis. Sometimes resembling viral pneumonia, pleural mesothelioma patients may present with shortness of breath, chest pain and/or persistent cough; some patients show no symptoms at all. A chest x-ray may show a build-up of fluid or pleural effusion (discussed below). The right lung is affected 60% of the time, with involvement of both lungs being seen in approximately 5% of patients at the time of diagnosis. Less common symptoms of pleural mesothelioma include fever, night sweats and weight loss. Symptoms of peritoneal mesothelioma may include pain or swelling in the abdomen due to a build-up of fluid, nausea, weight loss, bowel obstruction, anemia or swelling of the feet.
PLEASE KEEP IN MIND THAT THESE SYMPTOMS MAY BE CAUSED BY MESOTHELIOMA OR BY OTHER LESS SERIOUS CONDITIONS. ONLY A DOCTOR CAN MAKE A DEFINITIVE DIAGNOSIS.
Information on the symptoms, diagnosis, staging, and treatment of peritoneal mesothelioma.
Information on the symptoms, diagnosis, staging, and treatment of pleural mesothelioma.
PLEURAL EFFUSION
One of the most common symptoms of mesothelioma is a pleural effusion, or an accumulation of fluid between the parietal pleura (the pleura covering the chest wall and diaphragm) and the visceral pleura (the pleura covering the lungs). Both of these membranes are covered with mesothelial cells which, under normal conditions, produce a small amount of fluid that acts as a lubricant between the chest wall and the lung. Any excess fluid is absorbed by blood and lymph vessels maintaining a balance. When too much fluid forms, the result is an effusion.
TYPES
Pleural effusion is broken down into two categories, transudates and exudates. A transudate is a clear fluid that forms not because the pleural surfaces are diseased, but because of an imbalance between the normal production and removal of the fluid. The most common cause of transudative fluid is congestive heart failure. An exudate, which is often cloudy and contains many cells and proteins, results from disease of the pleura itself, and is common to mesothelioma. To determine whether a fluid is a transudate or exudate, a diagnostic thoracentesis, in which a needle or catheter is used to obtain a fluid sample, may be conducted.
SYMPTOMS
As the volume of fluid increases, shortness of breath, known as "dyspnea", and sometimes pain, ranging from mild to stabbing, may occur. Some patients may experience a dry cough. When the doctor listens to the patient’s chest with a stethoscope, normal breath sounds are muted, and tapping on the chest will reveal dull rather than hollow sounds.
DIAGNOSIS
Diagnosis of pleural effusion is usually accomplished with a simple chest x-ray, although CT scans or ultrasound may also be used. A special x-ray technique, called a lateral decubitus film, may be used to detect smaller effusions or to enable the physician to estimate of the amount of fluid present. If the underlying cause of the effusion is readily apparent (such as in the case of severe congestive heart failure), sampling of the fluid may not be necessary, however, because pleural effusion may be symptomatic of a number of disease processes from benign to malignant, a fluid sample is generally taken. Diagnostic thoracentesis, in which cells are extracted from the pleural cavity, is commonly done when the possibility of mesothelioma exists, however, in up to 85% of cases, the fluid tests negative or inconclusive even though cancer is present. It is ultimately a needle biopsy of the pleura (lining of the lung) or an open surgical biopsy which confirms a mesothelioma diagnosis.
TREATMENT
Pleural effusion caused by heart failure or infection can usually be resolved by directing treatment at the cause, however, when testing has realized no diagnosis, and fluid continues to build or recur, doctors may recommend chest tube drainage and chemical pleurodesis. Chemical pleurodesis is a technique in which a sclerosing agent is used to abrade the pleural surfaces producing an adhesion between the parietal and visceral pleurae. This will prevent further effusion by eliminating the pleural space. Talc appears to be the most effective agent for pleurodesis, with a success rate of nearly 95%. It is highly effective when administered by either poudrage or slurry. Poudrage is the most widely used method of instilling talc into the pleural space. Before spraying the talc, the medical team removes all pleural fluid to completely collapse the lung. After the talc is administered, they inspect the pleural cavity to be sure the talc has been evenly distributed over the pleural surface. Some doctors prefer to use talc mixed with saline solution which forms a wet slurry that can roll around the pleural cavity.

MESOTHELIOMA DIAGNOSIS
HOW IS MESOTHELIOMA DIAGNOSED?
A diagnosis of mesothelioma is most often obtained with careful assessment of clinical and radiological findings in addition to a confirming tissue biopsy. (Learn about typical mesothelioma symptoms.) A review of the patient's medical history, including history of asbestos exposure is taken, followed by a complete physical examination, x-rays of the chest or abdomen, and lung function tests. A CT scan or MRI may also be done at this time. If any of these preliminary tests prove suspicious for mesothelioma; a biopsy is necessary to confirm this diagnosis.
IMAGING TECHNIQUES AND THEIR VALUE IN DIAGNOSING AND ASSESSING MESOTHELIOMA
There are several imaging techniques which may prove useful when mesothelioma is suspected due to the presence of pleural effusion combined with a history of occupational or secondary asbestos exposure. While these imaging techniques can be valuable in assessing the possibility of the cancer, definitive diagnosis is still most often established through fluid diagnosis or tissue biopsy.
Some of the most commonly used imaging methods include:
• X-ray
A chest x-ray can reveal pleural effusion (fluid build-up) which is confined to either the right (60%) or left (40%) lung. On occasion, a mass may be seen. Signs of prior non-cancerous asbestos disease, such as pleural plaques or pleural calcification, or scarring due to asbestosis may also be noted.
• Computed Tomography (CT)
CT scans are also able to define pleural effusion, as well as pleural thickening, pleural calcification, thickening of interlobular fissures, or possible chest wall invasion. CT, however, is not able to differentiate between changes associated with benign asbestos disease (pleural disease), or differentiate between adenocarcinoma of the lung wh
ich may have spread to the pleura verses mesothelioma. CT scans may also be valuable in guiding fine needle aspiration of pleural masses for tissue diagnosis.
• Magnetic Resonance Imaging (MRI)
MRI scans are most often used to determine the extent of tumor prior to aggressive treatment. Because they provide images in multiple planes, they are better able to identify tumors as opposed to normal structures. They are also more accurate than CT scans in assessing enlargement of the mediastinal lymph nodes (those lymph nodes which lie between the two lungs), as well as a clear diaphragmatic surface, both of which play an important role in surgical candidacy.
• Positron Emission Tomography (PET)
PET imaging is now becoming an important part of the diagnosis and evaluation of mesothelioma. While PET scans are more expensive than other types of imaging, and are not always covered under insurance, they are now considered to be the most diagnostic of tumor sites, as well as the most superior in determining the staging of mesothelioma.Further explanation of PET scans.
• CT/PET
For patients who may be candidates for aggressive multimodality treatment (surgery, chemotherapy and radiation), accurate clinical staging is extremely important. Integrated CT/PET imaging provides a relatively new tool in this respect, and has become the imaging technique of choice for determining surgical eligibility. By combining the benefits of CT and PET (anatomic and metabolic information) into a single scan, this technology can more accurately determine the stage of the cancer, and can help identify the best treatment option for the patient. Read about a study of CT-PET imaging in preoperative evaluation of patients with malignant pleural mesothelioma.
A needle biopsy of the mass, or the removal and examination of the fluid surrounding the lung, may be used for diagnosis, however, because these samples are sometimes inadequate as far as determining cell type (epithelial, sarcomatous, or mixed) or because of the unreliability of fluid diagnosis, open pleural biopsy may be recommended. In a pleural biopsy procedure, a surgeon will make a small incision through the chest wall and insert a thin, lighted tube called a thoracoscope into the chest between two ribs. He will then remove a sample of tissue to be reviewed under a microscope by a pathologist. In a peritoneal biopsy, the doctor makes a small incision in the abdomen and inserts a peritoneoscope into the abdominal cavity.
Once mesothelioma is suspected through imaging tests, it is confirmed by pathological examination. Tissue is removed, put under the microscope, and a pathologist makes a definitive diagnosis, and issues a pathology report. This is the end of a process that usually begins with symptoms that send most people to the doctor: a fluid build-up or pleural effusions, shortness of breath, pain in the chest, or pain or swelling in the abdomen. The doctor may order an x-ray or CT scan of the chest or abdomen. If further examination is warranted, the following tests may be done:
• Video-Assisted Thoracoscopic Surgery (VATS)
Over the past decade, the use of video-assisted thoracic surgery (VATS) has become one of the most widely used tools in the diagnosis of mesothelioma. Biopsies of the pleural lining, nodules, masses and pleural fluid can now easily be obtained using this minimally invasive procedure, and other therapies such as pleurodesis (talc) for pleural effusions can be done concurrently.While the patient is under general anesthesia, several small incisions or “ports” are made through the chest wall. The surgeon then inserts a small camera, via a scope, into one incision, and other surgical instruments used to retrieve tissue samples into the other incisions. By looking at a video screen showing the camera images, the surgeon is able to complete whatever procedures are necessary
In many cases, this video-assisted technique is able to replace thoracotomy, which requires a much larger incision to gain access to the chest cavity, and because it is minimally invasive, the patient most often has less post-operative pain and a potentially shorter recovery period.
• Thoracoscopy
For pleural mesothelioma the doctor may look inside the chest cavity with a special instrument called a thoracoscope. A cut will be made through the chest wall and the thoracoscope will be put into the chest between two ribs. This test is usually done in a hospital with a local anesthetic or painkiller.
If fluid has collected in your chest, your doctor may drain the fluid out of your body by putting a needle into your chest and use gentle suction to remove the fluid. This is calledthoracentesis.
• Peritoneoscopy
For peritoneal mesothelioma the doctor may also look inside the abdomen with a special tool called a peritoneoscope. The peritoneoscope is put into an opening made in the abdomen. This test is usually done in the hospital under a local anesthetic.
If fluid has collected in your abdomen, your doctor may drain the fluid out of your body by putting a needle into your abdomen and using gentle suction to remove the fluid. This process is called paracentesis.
• Biopsy
If abnormal tissue is found, the doctor will need to cut out a small piece and have it looked at under a microscope. This is usually done during the thoracoscopy or peritoneoscopy, but can be done during surgery. More on needle biopsies.

PATHOLOGY AND THE ROLE OF PATHOLOGISTS IN THE DIAGNOSTIC PROCESS
Pathology, or the scientific study of cells, tissue, or fluid taken from the body is an integral part of a mesothelioma diagnosis. Most hospitals have their own pathology labs staffed by board-certified pathologists and licensed technologists. The importance of pathological diagnosis can not be underestimated, since the course of treatment is dependent upon an accurate diagnosis.
To make a diagnosis, pathologists examine tissue under a microscope, and based on established criteria, make a determination of benign vs. malignant cells. (More on biopsy tissue processing.) Subsequently, the type of cancer is determined. Although most pathologists have a general expertise of various diseases, a small number acquire training in a subspecialty, such as mesothelioma. These are physicians who have received world-wide recognition as premier experts, and have achieved high acclaim for their research, published articles and abstracts, and teaching. For a list of expert pathologists in the field of mesothelioma diagnosis, please call the MW toll free at 1-877-367-6376 or fill in the form at the bottom of this page specifying your request.
Knowing the stage is a factor in helping the doctor form a treatment plan. Mesothelioma is considered localized if the cancer is confined to the pleura, or advanced if it has spread beyond the pleura to other parts of the body such as the lungs, chest wall, abdominal cavity, or lymph nodes.
IMMUNOHISTOCHEMICAL MARKERS FOR MESOTHELIOMA
A diagnosis of any specific type of cancer often means ruling out other cancers in the process. This is true in the case of mesothelioma, where the most common “differential diagnosis” is that of adenocarcinoma versus mesothelioma.
During the biopsy procedure, the surgeon removes tissue samples to be sent to the laboratory. In the lab, slides are produced and then viewed and analyzed by a pathologist. These tissue specimens arrive at the lab with a request form that details patient information and history along with a description of the site in the body from which the specimen was obtained. Each individual specimen is numbered for each patient.
The pathologist then does a “gross examination” which consists of describing the tissue, and then placing it in a plastic cassette. The cassettes are then placed in a fixative that preserves the tissue permanently. Once the tissue has been fixed, it is processed into a paraffin block that will allow the pathologist to slice off thin microscopic sections that will then be stained to determine the patient’s diagnosis.
Immunohistochemistry is defined as “a method of analyzing and identifying cell types based on the binding of antibodies to specific components of the cell”. It is this processthat helps diagnose mesothelioma versus adenocarcinoma (or other types of cancer).
Early on, the “markers” which helped distinguish mesothelioma from adenocarcinoma were “negative markers”; those expressed in adenocarcinomas, but not in mesotheliomas. This made it more difficult to confirm a diagnosis, because pathologists were dealing with the absence of, rather than the presence of certain markers. Some of these markers, which are normally “positive” in an adenocarcinoma diagnosis and “negative” in a mesothelioma diagnosis, are carcinoembryonic antigen (CEA), CD 15 (LeuM1), epithelial glycoprotein (Bg8), tumor glycoprotein (BerEp4) and tumor glycoprotein (MOC-31).
In more recent years, “positive markers” expressed by mesotheliomas have come to the forefront. Some of the markers which are normally “positive” in mesotheliomas and “negative” in adenocarcincomas are calretinin, cytokeratin 5, HBME-1, mesothelin, N-cadherin, thrombomodulin, vimentin and Wilm’s tumor gene product (WT-1).
It is important to remember that while the above markers are commonly used to help diagnose the epithelial sub-type of mesothelioma, that they may also be expressed in other types of cancer, and may not necessarily apply to the bi-phasic or sarcomatoid sub-types of mesothelioma. Your doctor can always contact a more specialized lab if he/she feels your diagnosis is in any way inconclusive.

MESOTHELIOMA DIAGNOSIS QUESTIONS
DOCTOR-PATIENT COMMUNICATION
An open line of communication between a patient and his or her physician is vital when dealing with a serious disease such as mesothelioma. There will be many questions regarding treatment, whether palliative or aggressive, choices to deal with, and life issues to confront. Being informed and proactive in your care will give you a sense of empowerment.
Although most physicians have limited time to spend with each patient at appointments, it is important to address issues as they occur and resolve them to the satisfaction of all parties involved. Initially, this may mean going to your appointment with a list of symptoms or concerns, or questions regarding specific tests that are recommended. Once mesothelioma has been diagnosed, you may have questions regarding treatment options.
Most questions from patients stem from an initial diagnosis of mesothelioma and subsequent treatment options. Following are some frequently asked questions regarding these two important issues.
WHAT IS MY DIAGNOSIS?
There are three types of mesothelioma. Pleural mesothelioma is a cancer of the lining of the lung (pleura), peritoneal mesothelioma is a cancer of the lining of the abdominal cavity (peritoneum), and pericardial mesothelioma is a cancer of the lining surrounding the heart (pericardium). Sub-types (or cell types) of mesothelioma are epithelioid (the most common, and considered the most amenable to treatment), sarcomatous (a much more aggressive form), and biphasic or mixed (a combination of both of the other cell types).
The structural appearance of cells under the microscope determine the cell or sub-type of mesothelioma. Epithelioid is the least aggressive; sarcomatoid, the most aggressive. The biphasic or mixed cell type shows structural elements of both of the other two. More on the histologic subtypes of mesothelioma.





Epithelioid mesothelioma tissue Sarcomatoid mesothelioma tissue



Biphasic mesothelioma tissue

MESOTHELIOMA STAGES
Treatment options are often determined by the stage of mesothelioma a patient is in. There are three staging systems currently in use for pleural mesothelioma and each one measures somewhat different variables; peritoneal mesothelioma is not staged.
Staging is the term used to describe the extent of a patient's cancer, based on the primary tumor and its spread in the body. It can help the medical team plan treatment, estimate prognosis and identify clinical trials for which the patient may be eligible.
Staging is based on a knowledge of how the cancer develops, from the primary tumor, to the invasion of nearby organs and tissues, to distant spread or metastasis. Staging systems have evolved over time, and they continue to change as scientists learn more about cancer. Some staging systems cover many different types of cancer, while others focus on more specific cancers. The TNM (primary tumor, regional lymph nodes, distant metastasis) is the most common staging system for mesothelioma.
Some elements common to most staging systems are:
• Location of the primary tumor.
• Size and number of the tumors.
• Lymph node involvement.
• Cell type and tumor grade.
• Metastasis.
Many cancer registries, such as the National Cancer Institute's Surveillance, Epidemiology, and End Results Program (SEER) use summary staging, a system used for all types of cancer. Summary staging groups cancer into five main categories:
• In situ - cancer that is present only in the layer of cells in which it began.
• Localized - cancer that is limited to the organ in which it began with no evidence of spread.
• Regional - cancer that has spread from the primary site to nearby lymph nodes or organs.
• Distant - cancer that has spread from the primary site to distant lymph nodes or organs.
• Unknown - cases where not enough information exists to indicate stage.
Several types of testing may be used to help doctors determine stage, and to formulate a treatment plan.
• Physical examinations. The doctor examines the body by looking, feeling and listening to anything out of the ordinary.
• Imaging techniques. Procedures such as x-rays, CT scans, MRIs and PET scans may show the location, size of the tumor and whether the cancer has spread.
• Laboratory tests. Studies of blood, urine, fluid and tissue can provide information about the cancer. Tumor markers, sometime elevated when cancer is present, may provide information.
• Pathology reports. Results of the examination of tissue samples can include information about the size of the tumor(s), extension into adjacent structures, type of cells and grade of the tumor. Results of the examination of cells in fluid, such as that from a mesothelioma-related pleural effusion, may also provide information.
• Surgical reports. Observations about the size and appearance of the tumor(s), lymph nodes and nearby organs.
Staging information should be provided to the patient by his doctor so that potential treatment plans can be discussed. Stage of the mesothelioma, as well as consideration of other factors such as age, health status and the patient's wishes may dictate different treatment options.
The oldest staging system and the one most often used is the Butchart System which is based mainly on the extent of primary tumor mass and divides mesotheliomas into four stages. The more recent TNM system considers variables of tumor in mass and spread, lymph node involvement, and metastasis. The Brigham System is the latest system and stages mesothelioma according to resectability (the ability to surgically remove) and lymph node involvement.
Butchart System – extent of primary tumor mass
• Stage I: Mesothelioma is present in the right or left pleura and may also involve the diaphragm on the same side.
• Stage II: Mesothelioma invades the chest wall or involves the esophagus, heart, or pleura on both sides. Lymph nodes in the chest may also be involved.
• Stage III: Mesothelioma has penetrated through the diaphragm into the lining of the abdominal cavity or peritoneum. Lymph nodes beyond those in the chest may also be involved.
• Stage IV: There is evidence of metastasis or spread through the bloodstream to other organs.
TNM System -- variables of T (tumor), N (lymph nodes), M (metastasis)
• Stage I: Mesothelioma involves right or left pleura and may also have spread to the lung, pericardium, or diaphragm on the same side. Lymph nodes are not involved.
• Stage II: Mesothelioma has spread from the pleura on one side to nearby lymph nodes next to the lung on the same side. It may also have spread into the lung, pericardium, or diaphragm on the same side.
• Stage III: Mesothelioma is now in the chest wall, muscle, ribs, heart, esophagus, or other organs in the chest on the same side with or without spread to lymph nodes on the same side as the primary tumor.
• Stage IV: Mesothelioma has spread into the lymph nodes in the chest on the side opposite the primary tumor, or extends to the pleura or lung on the opposite side, or directly extends into organs in the abdominal cavity or neck. Any distant metastases is included in this stage.
Brigham System: (variables of tumor resectability and nodal status)
• Stage I: Resectable mesothelioma and no lymph node involvement
• Stage II: Resectable mesothelioma but with lymph node involvement
• Stage III: Unresectable mesothelioma extending into chest wall, heart, or through diaphragm, peritoneum; with or without extrathoracic lymph node involvement
• Stage IV: Distant metastatic disease

HOW WAS THIS DIAGNOSIS DETERMINED, AND HOW ACCURATE WERE THE TESTS?
Although you probably took many different tests leading up to your diagnosis, a tissue biopsy is normally the final determining factor. Following are some tests your doctor may recommend, and what may or may not be concluded from these tests.
• X-rays, CT scans, and MRIs - See the imaging section for more on these techniques. On conventional x-ray film, mesothelioma appears as a markedly thickened, nodular, irregular pleural-based mass which covers the pleural surface. The tumor often encompasses the involved lung, but is only rarely seen bilaterally. Chest wall, diaphragmatic, and mediastinal invasion may be seen in advanced cases. Moderate to large pleural effusion is often noted on the affected side. On CT scan, pleural thickening greater than 1 cm can be identified in over 90% of cases; thickening which extends into the interlobular fissure is seen in 85% of cases. Absence of pleural thickening does not preclude mesothelioma, and at times, the only CT finding is that of pleural effusion.
• Cytology - Testing of the pleural fluid for malignant cells is considered to have limited value in diagnosing mesothelioma. Negative or inconclusive readings account for nearly 85% of all fluid tested. Even with a positive fluid report, many doctors prefer to perform a confirming tissue biopsy as long as it does not compromise the patient's health.
• Needle Biopsy - In this test, done under local anesthetic, a large hollow needle is inserted through the skin and into the chest cavity. The needle is then rotated, and as it is taken out, tissue samples are collected. Because of the small sample size of the tissue, this type of biopsy is considered to be only 25-60% accurate in diagnosing mesothelioma. Because tumor seeding may occur along the needle tract in approximately 20% of patients, local radiation therapy may be used in conjunction with this test.
• Open biopsy - This type of biopsy is considered to be the most accurate for mesothelioma diagnosis, and is the procedure of choice because it affords the pathologist a larger tissue sample.. It is done in a hospital under general anesthetic. As with a needle biopsy, local radiation may be used because of the possibility of tumor seeding.
CAN I BE TREATED BY THE DOCTOR WHO DIAGNOSED MY MESOTHELIOMA?
If the doctor who diagnosed your mesothelioma is your primary physician, he will most likely refer you to a local oncologist for treatment. The oncologist may offer what he or she feels are the best treatment options, or, if their knowledge of this disease is limited, may suggest you seek out a doctor who specializes in mesothelioma. Most often these physicians are located at larger, teaching hospitals such as those listed in theComprehensive Cancer Center Section. These facilities are ranked as state-of-the-art cancer centers, and are highly respected for their patient care and innovative cancer treatments. If your choice of treatment involves a radical surgical procedure or a clinical trial involving new, as yet unproven drugs, these facilities may be best for you. If your treatment involves an already-approved, standard form of chemotherapy, this can be carried out locally.
WHAT TREATMENT OPTIONS WILL I BE OFFERED?
Treatment options may vary according to the age and over-all health of the patient, and the extent of the disease. It is important to be informed of all available options for your particular case, so that you can make decision on the option you feel most comfortable with. Surgery, chemotherapy, and clinical trials, as well as new approaches such as photodynamic therapy, immunotherapy, and gene therapy may be offered. Speak openly with your doctor regarding suggested procedures. Questions may include:
• Why is this procedure best for me?
• What does the procedure entail?
• What are the advantages/disadvantages of this treatment (i.e, will this procedure limit my eligibility for other treatments)?
• What are the possible risks or adverse side effects?
• What are the response, survival, and mortality rates associated with this procedure?
IS PALLIATIVE TREATMENT AN OPTION?
In some circumstances, age, contributing health problems, or advanced disease may make aggressive treatment impossible. In these cases, palliative care (that which treats the symptoms, but not the disease itself) may be appropriate. If you opt for palliative care, it is doubly important to communicate fully with your doctor. Many symptoms of mesothelioma can be alleviated or substantially lessened if you are completely open with your doctor. Each time you have an appointment, tell your doctor how you feel, what discomfort you are experiencing, and your level of pain. A good doctor should be willing to address your questions and concerns.


MESOTHELIOMA TREATMENT OPTIONS
The treatment program for mesothelioma depends on many factors, including: the stage of the cancer, where the cancer is, how far the cancer has spread, how the cancer cells look under the microscope and the patient’s age and desires.
TIME MATTERS
People diagnosed with this disease are often told the expected survival rate is only eight to twelve months. However, specialists in treating malignant mesothelioma at the leading cancer centers often have better statistics.
For instance, the five-year survival rate has approached 40% for selected patients of Dr. David Sugarbaker at Brigham and Women’s Center in Boston. To qualify for Dr. Sugarbaker’s treatment you must meet certain criteria. One of them is being in the early stages of the disease, so time is of the essence. To find out more about Dr. Sugarbaker and other physicians and cancer centers specializing in mesothelioma click on Finding Specialists.
Keeping track of your medical treatment is useful and a personal medical records file can help.

TRADITIONAL CARE

There are three traditional kinds of treatment for patients with malignant mesothelioma:
• Surgery (taking out the cancer)
• Chemotherapy (using drugs to fight the cancer)
• Radiation Therapy (using high-dose x-rays or other high-energy rays to kill cancer cells)
Often two or more of these are combined in the course of treatment. (NEW! Click here for the newest trial of trimodal lung-sparing treatment for pleural mesothelioma: The Columbia Protocol.)

MESOMARK BLOOD TEST
In January 2007, the Food and Drug Administration (FDA) approved the MESOMARK assay to help monitor response to treatment in epithelial and bi-phasic malignant mesothelioma patients. A specific protein, or biomarker, called Soluble Mesothelin-Related Peptide (SMRP), may be released into the blood by mesothelioma cancer cells. By measuring the amount of SMRP in a blood sample, doctors may be able to better monitor a patient's progress. Based on the limited amount of data currently available, use of this test may be beneficial, but effectiveness has not been determined at this time. The MESOMARK blood test has NOT yet been approved for the early diagnosis of mesothelioma.
This test has been approved as a Humanitarian Use Device (HUD), meaning that physicians must follow certain procedures to qualify their patients for testing. Once the physician is certified, informational brochures will be sent to be distributed to each applicable patient.
Those wishing to take part in
MESOMARK testing will be asked to provide one or more samples of blood. The blood samples will then be sent to a national reference laboratory for testing. In conjunction with other clinical and laboratory data obtained by your doctor, decisions regarding your treatment and care may be simplified. You may discontinue testing at any time.
The costs associated with the MESOMARK blood test may not be covered under health insurance, therefore, you may be required to pay all or part of the costs out of pocket. It is recommended that you check with your insurance carrier to determine whether coverage is available under your policy.

SURGERY

DIAGNOSTIC PROCEDURES
As previously mentioned in the "Symptoms" section of this website, a diagnosis of mesothelioma from fluid is many times inconclusive. Given this fact, diagnostic surgery becomes a necessary next step in confirming and staging mesothelioma.
Thoracoscopy enables a physician to evaluate the pleural cavity and to conduct multiple tissue biopsies under direct vision. In up to 98% of cases, a definitive diagnosis can be obtained. Often, chemical pleurodesis aimed at relieving the accumulation of fluid in the intrapleural space, can be accomplished during the same procedure. It is also possible to gauge the extent of the tumor, and make a determination of surgical resectability. While less invasive than an open biopsy, it can only be performed on patients where tumor has not obliterated the pleural space.
VATS, or video-assisted thoracic surgery is an alternative to thoracoscopy, although because of its more invasive nature, concerns of tumor seeding increase. By utilizing small incisions, the physician can view the pleural space with the assistance of a camera, and obtain sufficient tissue samples for analysis by a pathologist. Extent of the tumor (i.e., pleural involvement, chest wall invasion) may also determined, and recommendation as to the type of debulking procedure necessary can be made at this time.
Mediastinoscopy is sometimes used as an aid in staging extent of disease when enlarged nodes are seen using imaging techniques.
Laproscopy is used in mesothelioma patients in cases where imaging techniques suggest possible invasion of the tumor through the diaphragm. This information can be important in evaluating a patient for potential pleurectomy or extrapleural pneumonectomy.
PALLIATIVE PROCEDURES
Palliative surgical procedures are those which treat a symptom of mesothelioma, without aggressively treating the disease itself.
Chest Tube Drainage and Pleurodesis is considered the most common of palliative treatments. Fluid build-up, or pleural effusion, is most often the first symptom which will prompt mesothelioma patients to seek medical attention. Once this effusion has occurred, it is many times persistent, returning rapidly after initial thoracentesis (draining of the fluid). In order to eliminate this problem, the pleural space must be closed. This is accomplished by use of a talc slurry or other sclerosing agent which produces an adhesion.
Thoracoscopy and Pleurodesis is done in conjunction with VATS using a powdered form of talc versus talc slurry. Both this and chest tube drainage and pleurodesis will be only effective if there is no tumor encasing the lung which restricts its expansion.
Pleuroperitoneal Shunt plays a limited role in palliation for several reasons. It involves placement of a catheter run under the skin from the pleural to the peritoneal cavity. Obstruction of the catheter and possible seeding of the tumor into the abdominal cavity may be concerns.
Pleurectomy, used as a palliative procedure, may be performed where more extensive surgery is not an option. In these cases, it is understood that all visible or gross tumor will not be removed. It is considered the most effective means of controlling pleural effusion in cases where the lung's expansion is restricted by disease.
POTENTIALLY CURATIVE PROCEDURES
These procedures are performed with "curative intent". Their goal is removal of all gross disease, with the knowledge that microscopic disease will most likely remain. Adjuvant therapy (another form of treatment in addition to the primary therapy) is typically aimed at eliminating residual disease.
For Pleural Mesothelioma:
• Pleurectomy/Decortication is usually performed on patients with early stage disease (Stage I and selected Stage II), and attempts to remove all gross tumor. If it is found that all tumor can not be removed without removing the lung, this may be done at the same time and is calledpneumonectomy.
• Extrapleural Pneumonectomy is considerably more radical than other surgical approaches, and should be carried out by surgeons with great expertise in evaluating patients and performing the procedure itself. (See Finding Specialists.) Because in the past surgery alone has failed to effect a cure, or even to help prolong life for any extended period of time, it is currently being combined with traditional chemotherapy and/or radiation, or other new approaches such as gene therapy, immunotherapy or photodynamic therapy.

General Patient Selection Criteria for Extrapleural Pneumonectomy
Extrapleural pneumonectomy is a serious operation, and doctors experienced in this procedure choose their patients carefully. It is up to each individual surgeon to advise the patient on its feasibility and to conduct whatever tests he/she feel are necessary to optimize the patient's chances for survival and recovery. Following is a general list of patient selection criteria. This list may not be all inclusive, and may vary according to the preference of the surgeon.
• Karnofsky Performance Status score of >70. This score relates to what symptoms of disease the patient may be experiencing and how well they are able to conduct their daily activities. Some surgeons may require a higher performance status than others.
• Adequate renal (kidney) and liver function tests; no significant kidney or liver disease.
• Normal cardiac function per electrocardiogram and echocardiography.
• Adequate pulmonary function to tolerate the surgery.
• Disease limited to the ipsilateral hemithorax (the same side of the chest in which the mesothelioma is located) with no penetration of the diaphragm, extension to the heart or extensive involvement of the chest wall.
• Age of the patient is taken into consideration, but may not be as important as their overall status.
Surgeries of this nature should always be done with a complete understanding of the possible benefits and risks involved. If you are considering surgery as a treatment option, speak openly with your doctor about your concerns, and be sure all of your questions are answered to your satisfaction.

For Peritoneal Mesothelioma:
• Cytoreductive Surgery is aimed at removing all or nearly all of the gross or visible tumor in the peritoneal cavity. In order to treat any remaining cancer cells, Intra-Peritoneal Hyperthermic (heated) Chemotherapy (IPHC) is then delivered to the abdominal cavity. The type of chemotherapy drug used may vary according to the physician’s preference. Click here for more ontreatment of peritoneal mesothelioma.

CHEMOTHERAPY
Chemotherapy is defined as the treatment of cancer using chemical substances. When cancer occurs, abnormal cells continue to divide uncontrolled. Anticancer, or chemotherapy drugs, work to destroy cancer cells by preventing them from multiplying. Read more on types of chemotherapy medicines.
PURPOSES OF CHEMOTHERAPY
Chemotherapy may be used to achieve different goals, depending on the stage of the cancer at the time of diagnosis and the age and health of the patient. Since chemotherapy for mesothelioma is not considered "curative", the goal is:
• To control the cancer by s ping its spread or slowing its growth.
• To shrink tumors prior to other treatments, such as surgery. This is called neoadjuvant chemotherapy.
• To destroy microscopic disease which may remain after surgery. This is called adjuvant chemotherapy.
• To relieve symptoms, such as pain. This is called palliative chemotherapy, and is given in cases when a drastic reduction in the tumor is not expected.
The most common use for chemotherapy in mesothelioma patients, is as an option for those who are not surgical candidates, however, various cancer centers are now conducting trials using the neoadjuvant approach. Alimta (pemetrexed) is a drug approvedby the Food and Drug Administration (FDA) for use with Cisplatin in the treatment of patients with malignant pleural mesothelioma whose disease is either unresectable or who are not candidates for curative surgery. Alimta is the first drug approval specific to mesothelioma.
The Alimta/Cisplatin chemotherapy regimen is the first Food and Drug Administration (FDA) approved treatment specifically for malignant pleural mesothelioma. This is currently considered the most effective first-line treatment for mesothelioma patients who are not surgical candidates. A multi-targeted antifolate drug, Alimta works by blocking the enzymes necessary for DNA copying and cell division. During the clinical trial process, Alimta/Cisplatin improved median survival for pleural mesothelioma patients by approximately three months over treatment with Cisplatin as a single agent. Eli Lilly's information on treatment with Alimta.
As with any medical treatment, it is important to discuss the use of Alimta with your doctor. This conversation should include all pertinent information regarding effectiveness, administration and possible side effects of the drug combination. It is also important to begin vitamin supplementation of B12 by injection during the week prior to treatment (to be repeated every 9 weeks), and folic acid by mouth daily (to be continued until 21 days after the last cycle of Alimta). Additionally, you will be given an oral steroid medication to minimize the risk of skin rash or other possible side effects. Your doctor will have information on the correct dosages of each medication. Be sure to tell your doctor of any other medications you are taking (including non-prescription drugs) so he may be aware of any adverse interactions.
Alimta/Cisplatin is administered to patients on an outpatient basis every 21 days. This cycle of treatment involves a 10-minute IV infusion of Alimta followed by a 2 hour infusion of Cisplatin. How many cycles of treatment you receive will be dependent on your response rate to the drug (regression of the tumor or halt to progression of the disease) and the side effects you might experience.
Side effects of Alimta/Cisplatin are mild to moderate for most mesothelioma patients, i.e., nausea, vomiting and fatigue, and can usually be managed by your doctor. For some patients, however, side effects may be debilitating, and may require a decrease in dosage or removal from the program. All potential side effects should be mentioned to your doctor. Never assume any complaint is minor.
ADMINISTRATION OF CHEMOTHERAPY
The most common way to administer chemotherapy is intravenously, or through a vein. A thin needle is inserted into a vein in the hand or in the lower arm. Intravenous administration of drugs allows for rapid entry into the blood stream. Drugs may also be delivered via catheters and/or ports.
• Catheters are soft, thin, flexible tubes placed into a large vein in the body. They remain in place for as long as they are needed.
• The catheter may sometimes be attached to a port, a small round plastic or metal disc placed under the skin on the chest. Ports also remain in place for as long as necessary.
Intraperitoneal chemotherapy may also be delivered through a catheter or a port. The catheter is inserted through the abdominal wall. Chemotherapy drugs can then be infused directly into the abdominal cavity. Ports may also be placed under the skin of the abdominal wall and the catheter tunneled between the skin and muscle into the peritoneum.
SIDE EFFECTS OF CHEMOTHERAPY
Cancer cells grow and divide more rapidly than normal cells, but some normal cells also multiply quickly, particularly those in the digestive tract, reproduction system, and hair follicles. It is the damage done to normal cells that causes side effects. The type of side effects you might experience and how severe they are, depend on the type of chemotherapy you are receiving, the dosage given and how your own body reacts. Before beginning any chemotherapy treatment, you will be asked to sign a consent form. Before signing the form, be sure your doctor informs you of all the facts regarding the treatment he/she will be administering, including information about the particular drug or combination of drugs to be used, the possible risks or side effects (including nausea and vomiting and peripheral neuropathy), the number of treatments you will receive and how often, and whether it will be given during a hospital stay or on an outpatient basis. More onvomiting and nausea from chemotherapy. More on peripheral neuropathy. More on anti-nausea treatment for chemotherapy patients.
Click here if you are interested in learning more about chemotherapy for mesotheliomaand the types of questions you should ask your doctor.

CHEMOTHERAPY SCHEDULES
How often you will receive chemotherapy will be determined by your doctor, taking into consideration factors such as the stage of your cancer, the types of drugs you receive, the anticipated toxicities of the drugs and the time necessary for your body to recover from these toxicities. The doctor may also consider whether the goal of the chemotherapy is to control the growth of the cancer, or to ease symptoms associated with the disease.
In general, chemotherapy treatment is administered in "cycles" — a "cycle" being defined as a period of treatment followed by a period of rest. This cycle allows the cancer cells to be attacked by the drugs, and then allows the body's normal cells time to recover. The combination of drugs used, the length of time to administer the drugs, how often they should be repeated and the number of cycles recommended have been analyzed throughly in clinical trials. For mesothelioma patients, the "standard" treatment is a combination of Alimta and cisplatin, administered IV, with a 10 minute infusion of Alimtafollowed by two hours of cisplatin, given in 21 day cycles. Modifications to this schedule may be made according to what your doctor feels is appropriate in your particular case.
The number of treatment cycles, or the length of time between the beginning and end of chemotherapy may vary, however in general, 3 to 4 cycles of treatment are given before response is evaluated; 2 to 3 cycles are considered a minimum to assess for effectiveness. After response to the treatment has been determined, the following criteria will be used to decide whether chemotherapy should continue:
• If there is shrinkage of the tumor, or the disease is kept stable, chemotherapy may be continued for as long as it can be tolerated and there is no disease progression.
• If there is continued disease progression, chemotherapy will be s ped, and the patient will be given alternative options.
The goal of setting a chemotherapy schedule is to make treatment as effective, timely and trouble-free as possible, but while the drugs are working to kill cancer cells, they may also affect healthy cells causing side effects. One of the most common side effects, and one your doctor will monitor carefully, is a chemotherapy-induced low white blood cell count(neutropenia) which means your immune system is weakened, therefore leaving you more prone to infection. While this side effect is anticipated when someone is undergoing chemotherapy, it can cause delays in your treatment schedule, or changes in the dosage of the drugs you will receive. Click here for more on understanding your blood counts.

NOTE TO PATIENTS:
Chemotherapy treatment should be a cooperative effort between you and your doctor. The interaction that takes place is important to your health. It will not only help you feel better, but will also address any potential problems with miscommunication.
1. It is necessary for your doctor to be aware of any side effects which may result from your chemotherapy treatment.
These may include:
• Fever of, or greater than 101 degrees
• Nausea or vomiting
• Diarrhea or constipation
• Fatigue
• Tingling or numbness in the fingers or toes
• Ringing in the ears
• Bruises or rashes
• Sores in the mouth or throat
2. Taking other medication of any kind can alter the effects of chemotherapy or cause undesirable interactions.
Be sure you report all over-the-counter and prescribed medicines to your doctor. Don’t take aspirin unless it has been approved by your doctor. Ask your pharmacist if aspirin is contained in any drugs you plan to purchase.
3. Take extra care with your daily health.
Try to maintain a stable weight by eating a healthy diet and drinking plenty of fluids. If your stomach is upset, ask your doctor for helpful hints or work with a nutritionist who can tailor a program to your needs. Brush your teeth after every meal, or if you can’t brush, rinse your mouth thoroughly with water.
Stay away from people who have colds or the flu. Chemotherapy can compromise your immune system and lower your resistance to germs. Make sure you keep appointments for blood work – these tests help your doctor monitor your health.

4. Be open about your feelings regarding your treatment.
It is normal to feel sad, angry or afraid, however, letting these emotions get out of control can be detrimental to your overall well-being. Seek out the help of family, friends, your doctor, a counselor or a support group.


RADIATION THERAPY
Radiation therapy, also called radiotherapy, treats cancer by using penetrating beams of high energy or streams of particles called radiation. In treating mesothelioma, radiation may be used aggressively in combination with surgery, or palliatively to control symptoms.
In an aggressive combined modality approach, radiation is used to attack microscopic or residual disease remaining in the chest cavity after extrapleural pnuemonectomy. An example of this is Intensity Modulated Radiation Therapy (IMRT), which uses x-rays of varying intensities in conjunction with computer generated images to deliver targeted radiation directly to cancer cells while reducing the amount of radiation to surrounding healthy tissue. More on Intensity Modulated Radiation Therapy (IMRT).
Used palliatively, radiation can help control metastases (spread) of the tumor along tracks left by invasive procedures such as thoracoscopy, needle biopsy and chest tube drainage, or to control disease symptoms, such as pain or shortness of breath.
An exciting new development in radiation oncology is tomotherapy. A brief description ofsteps in the helical tomotherapy process.

A WORD ABOUT NUTRITION

PATIENT'S BILL OF RIGHTS
The American Hospital Association has adopted a Patient's Bill of Rights which is good for families to review before embarking on any aggressive treatment.